2 Jul, 12 | by BMJ
Hospitals can be dangerous places. Two things happen to everyone admitted to hospital for more than a few hours—they are put to bed and are fed. Over half a century ago Richard Asher highlighted the obsession hospitals have with beds and the dangers of being confined to bed (BMJ 1947; doi: 10.1136/bmj.2.4536.967). Asher’s description of the dangers of lying in bed still has resonance today—“the blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, and the spirit evaporating from his soul.” In a sense not a lot has changed in that beds are undoubtedly the main currency in discussions with managers. Hospitals compare themselves by the number of beds under their control and performance is assessed by length of stay—in other words time in bed and doctors are compared by their bedside manner. Richer Asher appreciated the positive effects of going to bed when unwell but riled against the negative impact of overdose—prolonged length of stay which would have resonance with hospital mangers today.
As well as “superbugs” and blood clots, there are nowadays additional risks to being admitted to hospital beyond prolonged confinement to bed especially if you are unfortunate enough to have diabetes and need to take insulin injections. The last UK National Audit of in-patient diabetes care has again found that almost one third of people with diabetes admitted to hospital, experience a medication error with the most common being related to insulin prescribing. Bizarrely, people admitted specifically for the management of their diabetes were more likely to experience a medication error than those with diabetes who were in hospital for other reasons. The errors were not trivial with some unfortunate individuals ending up in severe hypoglycaemia or ketoacidosis.
One particular and recurring source of error related to hospital food both in terms of “suitability” for someone with diabetes and the timing of meals and insulin injections. To an outsider it does seem odd that we have still not solved the simple problem of working out the relationship of an insulin dose according to food and the prevailing blood glucose levels to achieve safe and effective control of diabetes. This is particularly relevant for people admitted to hospital who are unable for a variety of reasons to self-manage their diabetes. It seems that the tasks of checking blood glucose levels, prescribing, giving insulin, and serving meals are unrelated (and presumably rather unrewarding) tasks on a hospital ward and occur frequently in a random order. This is all in sharp contrast to the experience of increasing numbers of people living with type 1 diabetes where insulin dose adjustment, correcting for the prevailing glucose level, and carbohydrate “counting” are a sine qua non of modern outpatient diabetes care.
On behalf of people with diabetes unable to manage their own insulin in hospital, let’s give mathematicians and engineers the challenge of creating algorithmic rules for a safe dose of mealtime insulin based on simple patient characteristics such as body mass index, the target range of blood glucose levels, and a prior estimate of meal content. This could all be put into an electronic calculator attached to a bedside blood glucose meter with the data uploaded to a central area each morning to highlight problem areas. The meal arrives, the blood test is done, and computer says “yes”—it offers a safe and effective insulin dose with an accurate date and time stamp.
More radical would be to create the new role of a “diabetes gastronome”—part-time and trained (but not necessarily qualified in the traditional sense) in the nuances of food and insulin and responsible for mealtimes for people with diabetes in hospital. It would probably be cost effective and reduce length of stay which is still prolonged in people with diabetes compared to their non-diabetic counterparts.
In reality, this is very unlikely to ever happen as the NHS is notoriously resistant to change and hospitals are increasingly keen on risk-avoidance. The NHS is not especially interested in food—we put more effort into feeding prisoners in jail that we do looking after the nutrition of people in hospital.
David Kerr wears many hats, sometimes at the same time—diabetologist, editor of Diabetes Digest, researcher, and founder of VoyageMD.com, a free service for travellers with diabetes and Mylyfe.me, a service for women surviving breast cancer. He also believes that social media has the potential to be of huge benefit in improving medical care and practice. He holds a small amount of stock in CellNovo (a new insulin pump company) and Axon Telehealth.